Impact of Generic Art Chennai India Johns Hopkins Clinical Cohort
Abstract
Objectives
Examine HIV-1 plasma viral load (PVL) and genital tract (GT) viral load (GVL) and drug resistance in India.
Methods
At the YRG Centre for AIDS Inquiry and Education, Chennai, we tested: PVL in women on first-line ART for ≥six months; GVL when PVL >2000 copies/mL; and plasma, genital and proviral contrary transcriptase drug resistance when GVL >2000 copies/mL. Wilcoxon rank-sum and Fisher's exact tests were used to identify failure and resistance associations. Pearson correlations were calculated to evaluate PVL–GVL associations. Inter-compartmental resistance discordance was evaluated using generalized estimating equations.
Results
Of 200 women, 37% had detectable (>400 copies/mL) PVL and 31% had PVL >chiliad copies/mL. Of women with detectable PVL, 74% had PVL >2000 copies/mL, of which 74% had detectable GVL. College PVL was associated with college GVL. Paired plasma and genital sequences were available for 21 women; mean age of 34 years, median ART elapsing of 33 months, median CD4 count of 217 cells/mmthree, median PVL of 5.4 log10 copies/mL and median GVL of 4.6 log10 copies/mL. Drug resistance was detected in 81%–91% of samples and 67%–76% of samples had dual-course resistance. Consummate 3-compartment cyclopedia was seen in but x% of women. GT–proviral discordance was significantly larger than plasma–proviral discordance. GT or proviral mutations discordant from plasma led to clinically relevant resistance in 24% and 30%, respectively.
Conclusions
We identified high resistance and high inter-compartmental resistance discordance in Indian women, which might lead to unrecognized resistance transmission and re-emergence compromising treatment outcomes, particularly relevant to countries like Republic of india, where sexual HIV transmission is predominant.
Introduction
Art is changing the dynamics of the HIV epidemic through suppression of plasma viral load (PVL) and genital tract (GT) viral load (GVL). 1–v Despite viral suppression in plasma, replication tin occur in the GT increasing horizontal and vertical transmission risks. 6–fourteen Such compartmentalization and differential evolution between plasma and the GT can be attributed to differences in CD4 or co-receptor expression, 15–18 HIV-specific allowed pressure, 15 , 19–24 poor genital ART penetration causing selective pressure level, 25 inflammation from trauma 26 or sexually transmitted infections. 15 , 17 , 20 , 21 , 27–31 Resulting tissue-specific lineages tin can increase the take a chance of unrecognized drug resistance and tropism, 6–12 suggesting compartment-specific HIV replication milieu.
With increasing show for beneficial early on Fine art to reduce HIV transmission, 16 , 32 , 33 information on prevalence and correlates of viral replication and of drug resistance mutations (DRMs) in circulating and archived viruses and in the GT amongst treated individuals are needed, particularly in globally predominant HIV-1 subtypes. 34 These measures impact long-term ART management and resistance manual and can guide development of novel prevention interventions. 35–38
Genotyping of circulating plasma virus is the electric current standard for clinical direction before and upon ART failure; still, it may underestimate resistance in settings similar treatment interruptions or compromised adherence. 39–42 Though clinical significance of DRMs that are archived in cellular reservoirs remains controversial, 39–43 proviral genotyping may further inform treatment decisions. Genotyping of GT viruses is uncommon and three-compartment drug resistance concordance and their impacts are unknown.
PVL and GVL are college for the globally predominant HIV-1 subtype C. 43–l In a developing state like India, where subtype C predominates and heterosexual activity is the major mode of transmission, investigating viral shedding and GT resistance upon treatment failure and its discordance from circulating and archived viruses is important, equally it carries implications for resistance transmission and clinical outcome. Under the hypothesis of an existing inter-compartmental discordance in viral load and clinically relevant resistance, we examined PVL and GVL, as well every bit plasma, proviral and genital virus resistance, in South Indian women on beginning-line Art.
Methods
Study setting
Women were enrolled at the YRG Centre for AIDS Research and Education (YRG-CARE) clinic in Chennai, the largest customs-based tertiary HIV care institution in India, with >xx 000 registered patients. During the study menstruation (May 2009 to Nov 2011), 39% of dispensary patients were women and 60% were on Art, attending clinic every iii months. Treatment monitoring was based on WHO immunological and clinical criteria, without virological monitoring.
HIV-1 infected women were offered enrolment if they were: (i) ≥18 years old; (ii) on first-line Art (zidovudine/stavudine + lamivudine/emtricitabine + nevirapine/efavirenz, the recommended regimens at the time of the study) for >half dozen months; (iii) reporting >95% adherence in the by month; (4) without pelvic surgery in the by half-dozen months; (v) not significant; and (vi) not currently menstruating. Enrolled women had a screening visit during which demographics were collected from interview and nautical chart, including age, WHO stage, adherence in the past calendar month, history of pelvic/cervical surgeries, reproductive history, final menstrual flow, CD4 count and ART history.
Upon enrolment, PVL was tested and women with PVL >2000 copies/mL were invited for a follow-up visit inside 1 calendar month, i calendar week prior to their next estimated menstrual catamenia. This PVL threshold was called to increase the yield of plasma and genital genotyping in this pilot study. Participants were instructed not to take sexual intercourse, douche or insert whatever vaginal products for ≤48 h earlier the second visit. On that visit, boosted history was derived, including history of sexually transmitted diseases and employ of contraceptives (e.1000. oral contraceptive pills, hormonal contraceptive dermal implant, depomedroxyprogesterone acetate injection or intrauterine device); an boosted 10 mL of blood was collected, PBMCs were isolated 51 and stored at −75 ± v°C, and genital secretions were collected (every bit specified beneath).
Ethics
The study was canonical by Lifespan and YRG-CARE Institutional Review Boards. All participants provided written informed consent.
Genital specimen collection and processing
During the 2d visit, pelvic exam was performed to collect endocervical secretions, cervical vaginal lavage (CVL) and vaginal swab samples. Endocervical secretions were collected using four wicks (Tear FloTM), held in place for a 1–3 min wicking catamenia, and so removed and cut at the wick neck. Each pair of wicks was placed in a vial containing 500 μL of nucleic acid sequence-based distension (NASBA) buffer (bioMérieux, Durham, NC, USA) and stored at −75 ± five°C. CVL samples were collected by bathing the cervix and ectocervix three times with the same 10 mL of PBS, which was then aspirated and placed into a sterile 50 mL conical centrifuge tube. Cervical samples were examined under the microscope for scarlet blood cells and spermatozoa. Genital specimens were aliquotted within 4 h of collection and stored at −75 ± 5°C. Four vaginal swabs were collected prior to CVL drove and wet mountain specimens were prepared to diagnose trichomoniasis, candidiasis and bacterial vaginosis.
HIV genotyping from plasma, genital Tear FloTM and PBMCs was performed for all women with GVL >2000 copies/mL (to ensure loftier genotyping yield), who had negative results for co-infection with trichomoniasis, candidiasis and bacterial vaginosis (which may distort results).
Laboratory methods
All testing was performed at the YRG-CARE laboratory, accredited by the National Accredited Board of Laboratories (ISO 15189:2012). Plasma was separated from blood within four–six h of sampling and stored at −75±5°C. CD4 testing was washed as office of routine care using a two-color unmarried-platform period cytometer, FACS Count (Becton Dickson Immunocytometry Systems, San Jose, USA). PVL was done with the Roche COBAS Amplicor HIV-one Monitor test, version 1.5 (Roche Diagnostics, Branchburg, USA) as per the manufacturer's protocol with a 400 copies/mL lower detection limit. The aforementioned protocol was practical for GVL with minor modifications: Tear FloTM filter paper wicks were cut and placed in 600 μL of lysis buffer with a quantification standard and incubated at room temperature on a shaker for 45 min at 800 rpm, followed past add-on of 600 μL of 100% isopropanol to the supernatant and proceeding equally per the manufacturer's protocol. 52 The same 400 copies/mL lower detection limit was used.
Contrary transcriptase (RT; amino acid positions i–230) sequencing from plasma and GT was done as described. 53 , 54 Briefly, RNA was extracted from plasma using the QIAamp viral RNA extraction kit (QIAGEN, Valencia, CA, Usa) as per the manufacturer'due south protocol. Genital RNA was extracted from Tear FloTM using the Roche COBAS Amplicor, and used for quantification and sequencing. Plasma and genital RNA were then reverse transcribed to cDNA. The RT fragment was amplified from cDNA by nested PCR with RT primers and analysed on ane.5% agarose gel. DNA was extracted from PBMCs using a QIAamp Blood Mini Kit (QIAGEN) equally per the manufacturer'south instructions and stored at −75 ± 5°C. Amplification was performed by nested PCR and analysed on 1.v% agarose gel. Amplicons were so column-purified and sequenced with an ABI PRISM 3100 Genetic Analyzer (Applied Biosystems, Foster City, U.s.a.) with an ABI sequence analyzing software version three.7.
Sequence analysis
Sequences were interpreted for resistance using the Stanford HIV Database tools and clinically pregnant resistance was defined as intermediate or high levels to ≥one drug according to the Stanford penalty rules. 55 Phylogenetic analyses were performed with Mega version six.0 56 by maximum likelihood [k bootstraps; HKY model with gamma distribution based on FindModel (http://www.hiv.lanl.gov)]. Sequence quality control and distance estimation were with SQUAT 57 and subtyping with REGA. 56 , 58 Genetic distances were estimated to place the level of evolution between the three compartments and from each compartment to a subtype C consensus. The latter, created from 113 YRG-CARE subtype C sequences from treatment-naive patients available from 2007 to 2011, was used as the 'reference'. Such analyses are relevant for the understanding of resistance archival and its potential touch on resistance evolution, and of compartmental resistance discordance.
Statistical analysis
We hypothesized that among women with detectable PVL: (i) some will have suppressed GVL; (ii) some will take clinically relevant DRMs detected in genital samples and/or PBMCs only non in plasma; and (iii) demographic and clinical characteristics volition differ according to viral load and DRMs. To evaluate these hypotheses, we compared demographic and clinical measures between several subgroups: (i) women with versus without detectable PVL; (two) women with detectable PVL ≤2000 versus those with >2000 copies/mL; (three) women with detectable versus undetectable GVL, amid those with PVL >2000 copies/mL; and (four) women with versus without GT DRMs. Wilcoxon rank-sum tests were used to compare continuous measures (age, CD4 count, months on ART, PVL and GVL, where applicable) and Fisher's exact test for chiselled measures (Fine art regimen).
Pearson correlations were calculated to evaluate the strength of human relationship betwixt logx-transformed viral load in the plasma and GT. For comparing of drug resistance concordance, for each compartment comparison (A versus B; due east.chiliad. plasma versus GT, GT versus PBMCs and plasma versus PBMCs), patients were classified every bit 'concordant' or 'discordant'. 'Concordant' compartments are those with identical mutation patterns and 'discordant' compartments are those with one or more additional DRMs in one compartment that are not detected in the other. Discordance is captured using 3 categories: additional mutations in compartment A only, additional mutations in compartment B but, or compartments A and B both have additional mutations not institute in the other. Patients with detectable GVL were considered 'shedders'. Viral loads below the detection limit of the assay were provided the everyman rank (≤400 copies/mL, 'not detected' as 0; ≤400 copies/mL, 'detected' as 1). The presence of whatever discordance between compartments, measures of genetic distances between genotypes from unlike compartments, and between each of them and the consensus subtype C sequence, were compared using statistical methods for correlated data. Specifically, we fitted generalized estimating equations with either mutation discordance (aye/no) or genetic distance every bit the outcome and compartment as the covariate, and assumed an exchangeable correlation structure among the compartments from the same woman. We used models for binomial data for discordance and commonly distributed information for genetic altitude. Robust standard errors were used to compute 95% CIs and P values. All analyses were performed using R version 3.two.3. 59 , 60
Results
Characteristics of enrolled women
Two hundred women were enrolled according to the inclusion criteria ( Figure S1, available every bit Supplementary data at JAC Online), with a median age of 33 years, median CD4 count of 422 cells/mmthree, median ART elapsing of 35 months and a most common history of zidovudine/stavudine + lamivudine + nevirapine ART regimens (Table 1). Of the 200 women, 73 (37%) had PVL >400 copies/mL (assay's lower detection limit) and 62 (31%) had PVL >1000 copies/mL (WHO treatment failure threshold). Compared with women with suppressed PVL, women with detectable PVL presented with lower CD4 counts (median of 246 versus 530 cells/mm3; P<0.001) and were more likely on zidovudine/stavudine + lamivudine + nevirapine (48% versus 65%; P=0.02). However, this small report was not designed to compare unlike regimens and nosotros therefore did not enlarge this finding. Of the 73 women, 54 (27% of total accomplice) had PVL >2000 copies/mL and were invited for a follow-upwardly second visit for drove of genital secretion samples. Women with PVL >2000 copies/mL had a lower median CD4 count than those with PVL ≤2000 copies/mL (224 versus 383; P=0.03). Twelve of the 54 women invited for a follow-up visit failed to return. Those 12 were older than those who returned (median age 37 versus 33 years; P=0.04) but otherwise like.
Tabular array ane.
Characteristics of 200 screened S Indian women on commencement-line ART, overall and stratified by PVL failure status
| Screened (due north=200) | PVL >400 copies/mL (due north=73) | PVL ≤400 copies/mL (north=127) | P | |
|---|---|---|---|---|
| Historic period (years) | 33 (23–49) | 34 (23–49) | 33 (24–46) | 0.39 |
| PVL (log10 copies/mL) | 0 (0–5.88) | 4.59 (2.6–five.88) | — | — |
| CD4 jail cell count (cells/mm3) | 422 (15–1182) | 246 (15–832) | 530 (27–1182) | <0.001 |
| Art duration (months) | 35 (vi–122) | 35 (7–114) | 34 (6–122) | 0.43 |
| Art regimen | ||||
| zidovudine/stavudine + lamivudine + efavirenz | 51 (26%) | 20 (27%) | 31 (24%) | 0.02 |
| zidovudine/stavudine + lamivudine + nevirapine | 118 (59%) | 35 (48%) | 83 (65%) | |
| tenofovir + lamivudine/emtricitabine + efavirenz | 18 (9%) | 9 (12%) | ix (seven%) | |
| tenofovir + lamivudine + nevirapine | 13 (6%) | nine (12%) | 4 (3%) | |
| Screened (due north=200) | PVL >400 copies/mL (n=73) | PVL ≤400 copies/mL (n=127) | P | |
|---|---|---|---|---|
| Age (years) | 33 (23–49) | 34 (23–49) | 33 (24–46) | 0.39 |
| PVL (log10 copies/mL) | 0 (0–5.88) | 4.59 (2.6–5.88) | — | — |
| CD4 cell count (cells/mmthree) | 422 (15–1182) | 246 (15–832) | 530 (27–1182) | <0.001 |
| ART duration (months) | 35 (6–122) | 35 (vii–114) | 34 (6–122) | 0.43 |
| ART regimen | ||||
| zidovudine/stavudine + lamivudine + efavirenz | 51 (26%) | xx (27%) | 31 (24%) | 0.02 |
| zidovudine/stavudine + lamivudine + nevirapine | 118 (59%) | 35 (48%) | 83 (65%) | |
| tenofovir + lamivudine/emtricitabine + efavirenz | 18 (9%) | 9 (12%) | 9 (7%) | |
| tenofovir + lamivudine + nevirapine | 13 (6%) | ix (12%) | 4 (iii%) | |
Continuous measures are presented as median (range) and chiselled measures are presented every bit north (%).
Table one.
Characteristics of 200 screened Due south Indian women on first-line ART, overall and stratified by PVL failure status
| Screened (n=200) | PVL >400 copies/mL (northward=73) | PVL ≤400 copies/mL (n=127) | P | |
|---|---|---|---|---|
| Historic period (years) | 33 (23–49) | 34 (23–49) | 33 (24–46) | 0.39 |
| PVL (log10 copies/mL) | 0 (0–5.88) | 4.59 (2.6–5.88) | — | — |
| CD4 cell count (cells/mmthree) | 422 (fifteen–1182) | 246 (15–832) | 530 (27–1182) | <0.001 |
| ART duration (months) | 35 (6–122) | 35 (vii–114) | 34 (6–122) | 0.43 |
| ART regimen | ||||
| zidovudine/stavudine + lamivudine + efavirenz | 51 (26%) | 20 (27%) | 31 (24%) | 0.02 |
| zidovudine/stavudine + lamivudine + nevirapine | 118 (59%) | 35 (48%) | 83 (65%) | |
| tenofovir + lamivudine/emtricitabine + efavirenz | 18 (ix%) | 9 (12%) | 9 (vii%) | |
| tenofovir + lamivudine + nevirapine | 13 (6%) | nine (12%) | iv (3%) | |
| Screened (n=200) | PVL >400 copies/mL (n=73) | PVL ≤400 copies/mL (n=127) | P | |
|---|---|---|---|---|
| Age (years) | 33 (23–49) | 34 (23–49) | 33 (24–46) | 0.39 |
| PVL (log10 copies/mL) | 0 (0–5.88) | 4.59 (2.half dozen–five.88) | — | — |
| CD4 cell count (cells/mmthree) | 422 (fifteen–1182) | 246 (15–832) | 530 (27–1182) | <0.001 |
| Fine art duration (months) | 35 (6–122) | 35 (7–114) | 34 (6–122) | 0.43 |
| ART regimen | ||||
| zidovudine/stavudine + lamivudine + efavirenz | 51 (26%) | xx (27%) | 31 (24%) | 0.02 |
| zidovudine/stavudine + lamivudine + nevirapine | 118 (59%) | 35 (48%) | 83 (65%) | |
| tenofovir + lamivudine/emtricitabine + efavirenz | 18 (9%) | ix (12%) | 9 (7%) | |
| tenofovir + lamivudine + nevirapine | xiii (6%) | 9 (12%) | iv (3%) | |
Continuous measures are presented as median (range) and categorical measures are presented as northward (%).
PVL and GVL
The 42 women who attended a 2nd visit had pelvic examinations and were negative for genital trichomoniasis, candidiasis and bacterial vaginosis. Demographic, clinical and laboratory characteristics of these 42 women are shown in Table 2; median age of 33 years, median CD4 count of 230 cells/mmiii, median PVL of 5.2 logten copies/mL and median Fine art duration of 34 months, most commonly zidovudine/stavudine + lamivudine + nevirapine (45%). Of the 42 women, 31 (74%) were shedders, who had significantly college PVL (P<0.01) and were less likely to exist on a nevirapine-based ART regimen compared with non-shedders (P=0.02) (Table 2).
Table 2.
Characteristics of 42 enrolled women with detectable PVL, overall and stratified past detectable and undetectable GVL, and of 21 women with available paired plasma–GT genotypes
| PVL >2000 copies/mL (N=42) | Women with paired genotypes (n=21) | ||||
|---|---|---|---|---|---|
| total | shedders (n=31) | non-shedders (n=11) | P | ||
| Age (years) | 33 (23–49) | 34 (23–49) | 31 (27–38) | 0.28 | 34 (27–49) |
| CD4 cell count (cells/mmiii) | 230 (51–658) | 225 (55–496) | 239 (51–658) | 0.30 | 217 (55–485) |
| PVL (logx copies/mL) | 5.17 (iii.39–5.88) | 5.4 (three.8–5.ix) | 3.88 (3.4–5.9) | 0.01 | 5.41 (3.8–v.nine) |
| GVL (log10 copies/mL) | 3.94 (0–five.88) | 4.34 (2.half dozen–v.88) | — | — | 4.62 (three.3–5.9) |
| Art duration (months) | 33.5 (8–108) | 33 (8–76) | 35 (18–108) | 0.15 | 33 (viii–73) |
| ART regimen | |||||
| zidovudine/stavudine + lamivudine + efavirenz | 11/42 (26%) | 11/31 (35%) | 0/11 (0%) | half dozen/21 (29%) | |
| zidovudine/stavudine + lamivudine + nevirapine | 19/42 (45%) | 12/31 (39%) | vii/11 (64%) | 0.02 | 10/21 (48%) |
| tenofovir + lamivudine/emtricitabine + efavirenz | 4/42 (10%) | 4/31 (xiii%) | 0/eleven (0%) | 3/21 (14%) | |
| tenofovir + lamivudine + nevirapine | 8/42 (19%) | 4/31 (13%) | 4/eleven (36%) | 2/21 (10%) | |
| PVL >2000 copies/mL (Northward=42) | Women with paired genotypes (n=21) | ||||
|---|---|---|---|---|---|
| full | shedders (northward=31) | non-shedders (n=eleven) | P | ||
| Age (years) | 33 (23–49) | 34 (23–49) | 31 (27–38) | 0.28 | 34 (27–49) |
| CD4 prison cell count (cells/mm3) | 230 (51–658) | 225 (55–496) | 239 (51–658) | 0.30 | 217 (55–485) |
| PVL (log10 copies/mL) | 5.17 (3.39–5.88) | 5.4 (3.viii–5.9) | 3.88 (three.4–v.9) | 0.01 | v.41 (3.eight–v.9) |
| GVL (log10 copies/mL) | 3.94 (0–5.88) | 4.34 (2.6–5.88) | — | — | 4.62 (3.iii–5.9) |
| Art duration (months) | 33.v (8–108) | 33 (8–76) | 35 (eighteen–108) | 0.xv | 33 (8–73) |
| Fine art regimen | |||||
| zidovudine/stavudine + lamivudine + efavirenz | 11/42 (26%) | 11/31 (35%) | 0/xi (0%) | 6/21 (29%) | |
| zidovudine/stavudine + lamivudine + nevirapine | 19/42 (45%) | 12/31 (39%) | 7/11 (64%) | 0.02 | ten/21 (48%) |
| tenofovir + lamivudine/emtricitabine + efavirenz | 4/42 (10%) | 4/31 (13%) | 0/11 (0%) | 3/21 (14%) | |
| tenofovir + lamivudine + nevirapine | 8/42 (19%) | 4/31 (13%) | 4/11 (36%) | 2/21 (ten%) | |
Continuous measures are presented as median (range) and categorical measures are presented as n/N (%).
Tabular array two.
Characteristics of 42 enrolled women with detectable PVL, overall and stratified by detectable and undetectable GVL, and of 21 women with available paired plasma–GT genotypes
| PVL >2000 copies/mL (Due north=42) | Women with paired genotypes (n=21) | ||||
|---|---|---|---|---|---|
| total | shedders (n=31) | non-shedders (n=11) | P | ||
| Age (years) | 33 (23–49) | 34 (23–49) | 31 (27–38) | 0.28 | 34 (27–49) |
| CD4 cell count (cells/mmthree) | 230 (51–658) | 225 (55–496) | 239 (51–658) | 0.30 | 217 (55–485) |
| PVL (logx copies/mL) | five.17 (3.39–5.88) | v.4 (3.8–v.9) | 3.88 (3.four–5.9) | 0.01 | 5.41 (3.eight–5.9) |
| GVL (log10 copies/mL) | 3.94 (0–five.88) | 4.34 (2.6–5.88) | — | — | iv.62 (iii.3–5.ix) |
| ART elapsing (months) | 33.five (8–108) | 33 (viii–76) | 35 (18–108) | 0.15 | 33 (8–73) |
| Art regimen | |||||
| zidovudine/stavudine + lamivudine + efavirenz | 11/42 (26%) | 11/31 (35%) | 0/11 (0%) | 6/21 (29%) | |
| zidovudine/stavudine + lamivudine + nevirapine | 19/42 (45%) | 12/31 (39%) | vii/xi (64%) | 0.02 | 10/21 (48%) |
| tenofovir + lamivudine/emtricitabine + efavirenz | four/42 (10%) | 4/31 (13%) | 0/11 (0%) | iii/21 (14%) | |
| tenofovir + lamivudine + nevirapine | eight/42 (19%) | iv/31 (13%) | 4/11 (36%) | ii/21 (10%) | |
| PVL >2000 copies/mL (Due north=42) | Women with paired genotypes (n=21) | ||||
|---|---|---|---|---|---|
| full | shedders (north=31) | non-shedders (n=11) | P | ||
| Age (years) | 33 (23–49) | 34 (23–49) | 31 (27–38) | 0.28 | 34 (27–49) |
| CD4 cell count (cells/mm3) | 230 (51–658) | 225 (55–496) | 239 (51–658) | 0.xxx | 217 (55–485) |
| PVL (log10 copies/mL) | 5.17 (3.39–five.88) | 5.4 (3.8–5.9) | iii.88 (3.4–5.ix) | 0.01 | 5.41 (3.8–5.ix) |
| GVL (log10 copies/mL) | iii.94 (0–five.88) | four.34 (2.6–5.88) | — | — | 4.62 (3.3–v.nine) |
| Art elapsing (months) | 33.5 (8–108) | 33 (8–76) | 35 (18–108) | 0.15 | 33 (eight–73) |
| Fine art regimen | |||||
| zidovudine/stavudine + lamivudine + efavirenz | xi/42 (26%) | 11/31 (35%) | 0/eleven (0%) | 6/21 (29%) | |
| zidovudine/stavudine + lamivudine + nevirapine | 19/42 (45%) | 12/31 (39%) | seven/11 (64%) | 0.02 | ten/21 (48%) |
| tenofovir + lamivudine/emtricitabine + efavirenz | 4/42 (10%) | 4/31 (13%) | 0/11 (0%) | iii/21 (fourteen%) | |
| tenofovir + lamivudine + nevirapine | viii/42 (xix%) | four/31 (13%) | 4/11 (36%) | 2/21 (10%) | |
Continuous measures are presented every bit median (range) and categorical measures are presented every bit n/N (%).
The Spearman'due south correlation between PVL and GVL for the 42 women with PVL >2000 copies/mL was moderate (r 2 =0.50; P<0.011), demonstrating that women with higher PVL tend to have higher GVL (Figure 1). A somewhat similar moderate correlation (r 2 =0.44) was also seen in the group of 31 shedders (P=0.014).
Figure 1.
Relationship betwixt PVL and GVL in 42 S Indian women, and plasma–GT drug resistance cyclopedia in 21/42 women with available data.
Effigy 1.
Relationship betwixt PVL and GVL in 42 South Indian women, and plasma–GT drug resistance concordance in 21/42 women with available data.
Drug resistance in circulating and GT RNA and proviral DNA
Twenty-5 of 42 women (60%) with PVL >2000 copies/mL had GVL >2000 copies/mL and had RT genotyping attempted in the 3 compartments. Genotypes were non available for 4/25 women; genital RNA from two women could non be amplified and plasma and genital paired sequences from two other women did not cluster together phylogenetically. Median GVL for the subset with genotype data was significantly higher than for the four without genotypes (4.6 versus 3.7 log10 copies/mL; P<0.05). Paired plasma and genital sequences were obtained for these 21 women and PBMC genotypes were bachelor for 20 women. All paired sequences were of skillful quality and amassed well phylogenetically ( Effigy S2). All just one (subtype A) sample were HIV-1 subtype C.
Plasma drug resistance was seen in 91% (19/21), GT drug resistance was seen in 81% (17/21) and PBMC drug resistance was seen in 90% (xviii/20). Plasma NRTI resistance was seen in 76% (16/21), GT NRTI resistance was seen in 67% (14/21) and PBMC NRTI resistance was seen in 75% (xv/20). Plasma NNRTI resistance was seen in 91% (xix/21), GT NNRTI resistance was seen in 81% (17/21) and PBMC NNRTI resistance was seen in 90% (18/20). Plasma dual-form resistance was seen in 76% (xvi/21), GT dual-form resistance was seen in 67% (14/21) and PBMC dual-course resistance was seen in 75% (15/20) (P=not meaning). The nearly common mutations in all three compartments included lamivudine-associated M184V and mutations at NNRTI-associated positions 101, 103 and 190. Thymidine analogue mutations (TAMs) occurred in 12/16 (75%) women on zidovudine/stavudine and K65R occurred in 1/five (xx%) women on tenofovir-based regimens and in one woman on zidovudine + lamivudine + nevirapine. Specific DRMs per patient in the 3 compartments are demonstrated in Table 3 and in aggregate in Figure 2.
Table 3.
DRMs in plasma, GT and PBMCs
| ID | ART | Plasma | GT | PBMCs | |||
|---|---|---|---|---|---|---|---|
| NRTI | NNRTI | NRTI | NNRTI | NRTI | NNRTI | ||
| i | 3TC + d4T + NVP | L74V, M184V | K103N, V108I, Y181C, G190A, H221Y | L74V, M184V, T215Y | K103N, V108I, Y181C, G190A, H221Y | L74LV, M184V, T215SY | A98AG , K103N, V108IV, Y181C, G190A, H221HY |
| 2 | 3TC + ZDV + EFV | M184V, T215F | K101E, V106M, E138A, G190A | M41L, D67DN , M184V, T215F | K101E, V106M, E138A, G190A | M184V, T215F | K101E, V106M, E138A, G190A |
| 3 | ZDV + 3TC + NVP | V75IMV | K103N | V75IMV | K103N | M41L, V75I | K103N, F227L |
| 4 | ZDV + 3TC + EFV | M41L, E44D, D67N, T69D, K70R, V75M, M184V, L210W, T215Y | A98G, K101E, G190S | M41L, E44D, D67N, T69D, K70R, V75M, M184V, L210W, T215Y | A98G, K101E, K103KE, G190S | M41LM, E44ED, D67DN, T69 A D Northward T, K70KR, V75 I MV, M184V, L210W, T215Y | A98G, K101EK, G190S |
| five | ZDV + 3TC + NVP | E44D, D67N, T69D, M184V, T215Y | A98AG, K101E, G190S | E44D, D67N, T69D, M184V, T215Y | A98AG, K101E, G190S, H221Y | D67DN, M184MV, T215Y | K101EK, K103KN , G190S |
| 6 | 3TC + d4T + NVP | M184V | K103N, P225H | none | M184V | K103N, P225HP | |
| 7 | TDF + 3TC + NVP | K65R, M184V | K103N, V108I | K65R, K70T, M184V | K103N, V108I | K65R, K70KR , M184V | K103N, V108I |
| eight | ZDV + 3TC + NVP | K65KR, L74LV, M184V | Y181CY, G190A, M230L | L74V, M184V | G190A | M184MV | G190AG, F227FL, M230LM |
| nine | d4T + 3TC + NVP | K70KR, M184V | K101HKNQ, K103KN, Y181CY, G190AG | K70R, M184V, K219E | K101H, Y181C, G190A | M184V, K219EK | K101HKNQ, K103KN, Y181CY |
| 10 | d4T + 3TC + EFV | none | |||||
| 11 | ZDV + 3TC + EFV | none | V106M, F227L | none | K103N | none | V106M, F227L |
| 12 | FTC + TDF + EFV | none | none | E138EK | |||
| 13 | ZDV + 3TC + NVP | M184V, T215Y | Y181C | M184V, T215Y | V106M , Y181C | M184MV, T215 NS TY | K103KN , Y181CY |
| xiv | TDF + 3TC + NVP | none | K101E | none | K101E | none | K101E |
| 15 | 3TC + d4T + EFV | M184V | V106ILM, V179DV, Y188L | M184V | V106ILM, Y188L | M184V | Y188L |
| sixteen | TDF + 3TC + EFV | M184V | K103N, Y188L | M184V | K103N, Y188 H | M184V | K103N, Y188L |
| 17 | 3TC + d4T + NVP | M41L, D67N, V75M, M184V, T215Y | A98G, K101E, E138Q, G190A | M41L, E44D, D67N, V75I, M184V | A98G, K101E, E138Q, G190A | M41L, D67DN, V75M, M184V, T215Y | A98G, K101E, E138Q, G190A |
| 18 | TDF + 3TC + EFV | none | K101EK, Y188HY | none | |||
| xix | ZDV + 3TC + NVP | D67N, K70KR, M184V | Y181C | D67DN, K70KR, M184MV | E138AE | D67DN, K70KR, M184MV | Y181CY |
| twenty | ZDV + 3TC + NVP | D67N, M184V | A98G, K101E, G190A, P225H | none | Y181C | D67N, K70R, M184V, K219E | A98G, K101E, G190A |
| 21 | ZDV + 3TC + EFV | M41L, D67N, T69D, K70R, M184V, T215Y, K219E | Y188L, M230L | M41L, D67N, T69D, K70R, M184V, T215Y, K219E | Y188L, M230L | NA | |
| ID | ART | Plasma | GT | PBMCs | |||
|---|---|---|---|---|---|---|---|
| NRTI | NNRTI | NRTI | NNRTI | NRTI | NNRTI | ||
| 1 | 3TC + d4T + NVP | L74V, M184V | K103N, V108I, Y181C, G190A, H221Y | L74V, M184V, T215Y | K103N, V108I, Y181C, G190A, H221Y | L74LV, M184V, T215SY | A98AG , K103N, V108IV, Y181C, G190A, H221HY |
| 2 | 3TC + ZDV + EFV | M184V, T215F | K101E, V106M, E138A, G190A | M41L, D67DN , M184V, T215F | K101E, V106M, E138A, G190A | M184V, T215F | K101E, V106M, E138A, G190A |
| 3 | ZDV + 3TC + NVP | V75IMV | K103N | V75IMV | K103N | M41L, V75I | K103N, F227L |
| four | ZDV + 3TC + EFV | M41L, E44D, D67N, T69D, K70R, V75M, M184V, L210W, T215Y | A98G, K101E, G190S | M41L, E44D, D67N, T69D, K70R, V75M, M184V, L210W, T215Y | A98G, K101E, K103KE, G190S | M41LM, E44ED, D67DN, T69 A D N T, K70KR, V75 I MV, M184V, L210W, T215Y | A98G, K101EK, G190S |
| 5 | ZDV + 3TC + NVP | E44D, D67N, T69D, M184V, T215Y | A98AG, K101E, G190S | E44D, D67N, T69D, M184V, T215Y | A98AG, K101E, G190S, H221Y | D67DN, M184MV, T215Y | K101EK, K103KN , G190S |
| 6 | 3TC + d4T + NVP | M184V | K103N, P225H | none | M184V | K103N, P225HP | |
| 7 | TDF + 3TC + NVP | K65R, M184V | K103N, V108I | K65R, K70T, M184V | K103N, V108I | K65R, K70KR , M184V | K103N, V108I |
| 8 | ZDV + 3TC + NVP | K65KR, L74LV, M184V | Y181CY, G190A, M230L | L74V, M184V | G190A | M184MV | G190AG, F227FL, M230LM |
| 9 | d4T + 3TC + NVP | K70KR, M184V | K101HKNQ, K103KN, Y181CY, G190AG | K70R, M184V, K219E | K101H, Y181C, G190A | M184V, K219EK | K101HKNQ, K103KN, Y181CY |
| 10 | d4T + 3TC + EFV | none | |||||
| eleven | ZDV + 3TC + EFV | none | V106M, F227L | none | K103N | none | V106M, F227L |
| 12 | FTC + TDF + EFV | none | none | E138EK | |||
| thirteen | ZDV + 3TC + NVP | M184V, T215Y | Y181C | M184V, T215Y | V106M , Y181C | M184MV, T215 NS TY | K103KN , Y181CY |
| 14 | TDF + 3TC + NVP | none | K101E | none | K101E | none | K101E |
| fifteen | 3TC + d4T + EFV | M184V | V106ILM, V179DV, Y188L | M184V | V106ILM, Y188L | M184V | Y188L |
| xvi | TDF + 3TC + EFV | M184V | K103N, Y188L | M184V | K103N, Y188 H | M184V | K103N, Y188L |
| 17 | 3TC + d4T + NVP | M41L, D67N, V75M, M184V, T215Y | A98G, K101E, E138Q, G190A | M41L, E44D, D67N, V75I, M184V | A98G, K101E, E138Q, G190A | M41L, D67DN, V75M, M184V, T215Y | A98G, K101E, E138Q, G190A |
| 18 | TDF + 3TC + EFV | none | K101EK, Y188HY | none | |||
| xix | ZDV + 3TC + NVP | D67N, K70KR, M184V | Y181C | D67DN, K70KR, M184MV | E138AE | D67DN, K70KR, M184MV | Y181CY |
| 20 | ZDV + 3TC + NVP | D67N, M184V | A98G, K101E, G190A, P225H | none | Y181C | D67N, K70R, M184V, K219E | A98G, K101E, G190A |
| 21 | ZDV + 3TC + EFV | M41L, D67N, T69D, K70R, M184V, T215Y, K219E | Y188L, M230L | M41L, D67N, T69D, K70R, M184V, T215Y, K219E | Y188L, M230L | NA | |
3TC, lamivudine; d4T, stavudine; EFV, efavirenz; NVP, nevirapine; TDF, tenofovir; ZDV, zidovudine; FTC, emtricitabine; GS, genital secretion; NA, not amplified.
Discordant mutations that were detected in GS or in PBMCs and not in plasma are in bold. Discordant mutations that led (alone or in combination) to clinically significant predicted resistance to at least one drug are underlined.
Table 3.
DRMs in plasma, GT and PBMCs
| ID | Art | Plasma | GT | PBMCs | |||
|---|---|---|---|---|---|---|---|
| NRTI | NNRTI | NRTI | NNRTI | NRTI | NNRTI | ||
| 1 | 3TC + d4T + NVP | L74V, M184V | K103N, V108I, Y181C, G190A, H221Y | L74V, M184V, T215Y | K103N, V108I, Y181C, G190A, H221Y | L74LV, M184V, T215SY | A98AG , K103N, V108IV, Y181C, G190A, H221HY |
| 2 | 3TC + ZDV + EFV | M184V, T215F | K101E, V106M, E138A, G190A | M41L, D67DN , M184V, T215F | K101E, V106M, E138A, G190A | M184V, T215F | K101E, V106M, E138A, G190A |
| iii | ZDV + 3TC + NVP | V75IMV | K103N | V75IMV | K103N | M41L, V75I | K103N, F227L |
| 4 | ZDV + 3TC + EFV | M41L, E44D, D67N, T69D, K70R, V75M, M184V, L210W, T215Y | A98G, K101E, G190S | M41L, E44D, D67N, T69D, K70R, V75M, M184V, L210W, T215Y | A98G, K101E, K103KE, G190S | M41LM, E44ED, D67DN, T69 A D N T, K70KR, V75 I MV, M184V, L210W, T215Y | A98G, K101EK, G190S |
| 5 | ZDV + 3TC + NVP | E44D, D67N, T69D, M184V, T215Y | A98AG, K101E, G190S | E44D, D67N, T69D, M184V, T215Y | A98AG, K101E, G190S, H221Y | D67DN, M184MV, T215Y | K101EK, K103KN , G190S |
| vi | 3TC + d4T + NVP | M184V | K103N, P225H | none | M184V | K103N, P225HP | |
| 7 | TDF + 3TC + NVP | K65R, M184V | K103N, V108I | K65R, K70T, M184V | K103N, V108I | K65R, K70KR , M184V | K103N, V108I |
| 8 | ZDV + 3TC + NVP | K65KR, L74LV, M184V | Y181CY, G190A, M230L | L74V, M184V | G190A | M184MV | G190AG, F227FL, M230LM |
| nine | d4T + 3TC + NVP | K70KR, M184V | K101HKNQ, K103KN, Y181CY, G190AG | K70R, M184V, K219E | K101H, Y181C, G190A | M184V, K219EK | K101HKNQ, K103KN, Y181CY |
| ten | d4T + 3TC + EFV | none | |||||
| 11 | ZDV + 3TC + EFV | none | V106M, F227L | none | K103N | none | V106M, F227L |
| 12 | FTC + TDF + EFV | none | none | E138EK | |||
| 13 | ZDV + 3TC + NVP | M184V, T215Y | Y181C | M184V, T215Y | V106M , Y181C | M184MV, T215 NS TY | K103KN , Y181CY |
| 14 | TDF + 3TC + NVP | none | K101E | none | K101E | none | K101E |
| 15 | 3TC + d4T + EFV | M184V | V106ILM, V179DV, Y188L | M184V | V106ILM, Y188L | M184V | Y188L |
| 16 | TDF + 3TC + EFV | M184V | K103N, Y188L | M184V | K103N, Y188 H | M184V | K103N, Y188L |
| 17 | 3TC + d4T + NVP | M41L, D67N, V75M, M184V, T215Y | A98G, K101E, E138Q, G190A | M41L, E44D, D67N, V75I, M184V | A98G, K101E, E138Q, G190A | M41L, D67DN, V75M, M184V, T215Y | A98G, K101E, E138Q, G190A |
| 18 | TDF + 3TC + EFV | none | K101EK, Y188HY | none | |||
| 19 | ZDV + 3TC + NVP | D67N, K70KR, M184V | Y181C | D67DN, K70KR, M184MV | E138AE | D67DN, K70KR, M184MV | Y181CY |
| 20 | ZDV + 3TC + NVP | D67N, M184V | A98G, K101E, G190A, P225H | none | Y181C | D67N, K70R, M184V, K219E | A98G, K101E, G190A |
| 21 | ZDV + 3TC + EFV | M41L, D67N, T69D, K70R, M184V, T215Y, K219E | Y188L, M230L | M41L, D67N, T69D, K70R, M184V, T215Y, K219E | Y188L, M230L | NA | |
| ID | ART | Plasma | GT | PBMCs | |||
|---|---|---|---|---|---|---|---|
| NRTI | NNRTI | NRTI | NNRTI | NRTI | NNRTI | ||
| i | 3TC + d4T + NVP | L74V, M184V | K103N, V108I, Y181C, G190A, H221Y | L74V, M184V, T215Y | K103N, V108I, Y181C, G190A, H221Y | L74LV, M184V, T215SY | A98AG , K103N, V108IV, Y181C, G190A, H221HY |
| two | 3TC + ZDV + EFV | M184V, T215F | K101E, V106M, E138A, G190A | M41L, D67DN , M184V, T215F | K101E, V106M, E138A, G190A | M184V, T215F | K101E, V106M, E138A, G190A |
| 3 | ZDV + 3TC + NVP | V75IMV | K103N | V75IMV | K103N | M41L, V75I | K103N, F227L |
| 4 | ZDV + 3TC + EFV | M41L, E44D, D67N, T69D, K70R, V75M, M184V, L210W, T215Y | A98G, K101E, G190S | M41L, E44D, D67N, T69D, K70R, V75M, M184V, L210W, T215Y | A98G, K101E, K103KE, G190S | M41LM, E44ED, D67DN, T69 A D Northward T, K70KR, V75 I MV, M184V, L210W, T215Y | A98G, K101EK, G190S |
| five | ZDV + 3TC + NVP | E44D, D67N, T69D, M184V, T215Y | A98AG, K101E, G190S | E44D, D67N, T69D, M184V, T215Y | A98AG, K101E, G190S, H221Y | D67DN, M184MV, T215Y | K101EK, K103KN , G190S |
| vi | 3TC + d4T + NVP | M184V | K103N, P225H | none | M184V | K103N, P225HP | |
| seven | TDF + 3TC + NVP | K65R, M184V | K103N, V108I | K65R, K70T, M184V | K103N, V108I | K65R, K70KR , M184V | K103N, V108I |
| 8 | ZDV + 3TC + NVP | K65KR, L74LV, M184V | Y181CY, G190A, M230L | L74V, M184V | G190A | M184MV | G190AG, F227FL, M230LM |
| 9 | d4T + 3TC + NVP | K70KR, M184V | K101HKNQ, K103KN, Y181CY, G190AG | K70R, M184V, K219E | K101H, Y181C, G190A | M184V, K219EK | K101HKNQ, K103KN, Y181CY |
| ten | d4T + 3TC + EFV | none | |||||
| 11 | ZDV + 3TC + EFV | none | V106M, F227L | none | K103N | none | V106M, F227L |
| 12 | FTC + TDF + EFV | none | none | E138EK | |||
| 13 | ZDV + 3TC + NVP | M184V, T215Y | Y181C | M184V, T215Y | V106M , Y181C | M184MV, T215 NS TY | K103KN , Y181CY |
| fourteen | TDF + 3TC + NVP | none | K101E | none | K101E | none | K101E |
| xv | 3TC + d4T + EFV | M184V | V106ILM, V179DV, Y188L | M184V | V106ILM, Y188L | M184V | Y188L |
| 16 | TDF + 3TC + EFV | M184V | K103N, Y188L | M184V | K103N, Y188 H | M184V | K103N, Y188L |
| 17 | 3TC + d4T + NVP | M41L, D67N, V75M, M184V, T215Y | A98G, K101E, E138Q, G190A | M41L, E44D, D67N, V75I, M184V | A98G, K101E, E138Q, G190A | M41L, D67DN, V75M, M184V, T215Y | A98G, K101E, E138Q, G190A |
| eighteen | TDF + 3TC + EFV | none | K101EK, Y188HY | none | |||
| 19 | ZDV + 3TC + NVP | D67N, K70KR, M184V | Y181C | D67DN, K70KR, M184MV | E138AE | D67DN, K70KR, M184MV | Y181CY |
| 20 | ZDV + 3TC + NVP | D67N, M184V | A98G, K101E, G190A, P225H | none | Y181C | D67N, K70R, M184V, K219E | A98G, K101E, G190A |
| 21 | ZDV + 3TC + EFV | M41L, D67N, T69D, K70R, M184V, T215Y, K219E | Y188L, M230L | M41L, D67N, T69D, K70R, M184V, T215Y, K219E | Y188L, M230L | NA | |
3TC, lamivudine; d4T, stavudine; EFV, efavirenz; NVP, nevirapine; TDF, tenofovir; ZDV, zidovudine; FTC, emtricitabine; GS, genital secretion; NA, not amplified.
Discordant mutations that were detected in GS or in PBMCs and not in plasma are in assuming. Discordant mutations that led (lone or in combination) to clinically significant predicted resistance to at least one drug are underlined.
Effigy 2.
Prevalence of DRMs in plasma, GT and PBMCs.
Figure two.
Prevalence of DRMs in plasma, GT and PBMCs.
Drug resistance discordance
Complete DRM cyclopedia in all three compartments occurred in only 2/xx (10%) women for which sequences from all compartments were available, one of whom had no DRMs; 5/21 (24%) between plasma and GT, 8/20 (xl%) between plasma and PBMCs and iii/20 (fifteen%) betwixt GT and PBMCs (Table 3). Odds of any discordance between GT and PBMCs was significantly larger than any discordance between plasma and PBMCs (OR = v.35; 95% CI = 1.09–26.18; P=0.04). The odds of discordance between plasma and GT was also larger than betwixt plasma and PBMCs, but not significantly and then (OR = 2.56; 95% CI = 0.46–xiv.x; P=0.28).
Of the sixteen women with plasma–GT discordance, 12 (75%) had, overall, 14 additional DRMs in GT not detected in plasma (bold in Tabular array 3). Of these, 8 discordant mutations (underlined in Tabular array three) led to clinically relevant college predicted resistance in GT versus plasma to at least 1 drug in 5/21 (24%) women.
Of the 12 women with plasma–PBMC discordance, 10 (83%) had, overall, 15 DRMs in PBMCs not detected in plasma (assuming in Tabular array three). Of these, 12 discordant mutations (underlined in Table 3) led to clinically relevant college predicted resistance in PBMCs than plasma to at to the lowest degree ane drug in 6/20 (thirty%) women.
There was no statistically significant difference in genital shedding betwixt the plasma–GT concordant and discordant groups, which may be due to small sample sizes (Figure 1). However, women with concordant mutations between the 2 compartments (blackness circles in Figure 1) did announced in the higher ends of both PVL and GVL. Tabular array S1 demonstrates characteristics of women co-ordinate to sequence cyclopedia among compartments. While non statistically significant, college plasma–PBMC discordance was seen in women with longer time on Art, and amid all compartments with zidovudine/stavudine + lamivudine + nevirapine regimens.
Genetic distances
Genetic distances between pairs of sequences from the three compartments were similar overall (mean 1.78% plasma–GT, 2.01% plasma–PBMCs and 2.27% PBMC–GT). On average, compared with plasma–GT, plasma–PBMC distances were 0.22 units higher (95% CI = −0.38–0.81; P=0.471) and PBMC–GT distances were 0.48 units college (95% CI = −0.18–1.14; P=0.155). Models comparing genetic distances between each compartment and the subtype C reference sequence showed that on average, compared with PBMCs (hateful viii.27%), genetic distances of GT sequences were 8.98% (0.77 units higher; 95% CI = 0.16–ane.37; P=0.013) and genetic distances of plasma sequences were 9.01% (0.80 units higher; 95% CI = 0.30–i.29; P=0.002).
Word
We investigated the compartmentalization of HIV-1 in plasma, GT and PBMCs and determined virological failure, GT viral shedding and inter-compartmental drug resistance concordance in HIV-1 subtype C-infected Southward Indian women on first-line ART. Nosotros found loftier resistance levels and, supporting our hypotheses, we demonstrated a fair, not perfect, plasma–genital viral load cyclopedia, and loftier drug resistance discordance among the three compartments, with 71% (15/21) of women having DRMs in genital and/or PBMCs that were not detected in plasma, which might impact clinical intendance.
Depending on the threshold, virological failure was detected in 31%–37% of women and, in line with previous reports, was associated with lower CD4 counts 61 and higher use of nevirapine-based regimens. Consistent with the literature, 27 , 48 , 62 , 63 74% of women with PVL >2000 copies/mL were genital shedders with a moderate but significant PVL–GVL concordance. This finding is supportive of PVL serving as a surrogate marker for genital shedding. 15 , 64 Though we did non quantitate GVL in women with undetectable PVL, which might accept underestimated genital shedding, this finding supports previous studies. 13 , 65 , 66
Suppression of GT viral replication is essential to prevent evolution and transmission of resistance, and would have an epidemiological bear on in places like India, where sexual contact is the main transmission cause. To forbid compartmentalization of HIV replication in the GT, xiv , 31 , 67 , 68 all Art components should reach adequate concentrations in that compartment. Though further such studies are needed, 65 some propose that failure to suppress PVL is the main determinant of GT shedding. 69–72 Equally our study participants were more immunocompromised and had college GVL compared with other studies, 50 the risk of vertical and horizontal resistance transmission is presumably greater. 73
High, fairly like, levels of resistance (any in 81%–91%; dual-grade in 67%–76%) were detected in all compartments, but with loftier discordance: only 10% of women had total DRM design cyclopedia amongst the iii compartments, with slightly college rates between plasma and GT (24%) and between plasma and PBMCs (40%). These results are consistent with previous findings, implying the potential inadequacy of plasma genotyping equally a representative for other anatomical sites. 65 Moreover, these discordant mutations led to clinically relevant GT resistance that was not detected in plasma in 24% of women, and in PBMCs in 30%. These differences may suggest distinct viral evolution, possibly attributed to variable drug penetration/concentration, not measured hither, 14 , 74–76 but could also be the upshot of sampling bias between compartments, associated for case with different viral loads. 77 Additionally, ART reduces viral load in plasma and the GT only does not diminish proviral DNA, 78 which, even in the absence of detectable plasma RNA, can promote both perinatal and heterosexual resistance transmission. 66 , 79
Observed DRM patterns were, overall, as expected, eighty with lamivudine-associated M184V nigh oft observed in all three compartments. Reported good GT penetration of lamivudine 64 , 75 may explicate our observed decreased frequency of M184V in that compartment compared with plasma (62% versus 71%). Regarding zidovudine/stavudine-associated TAMs, previous reports suggest that zidovudine tin can penetrate the GT in equal or higher concentrations than the blood plasma, whereas stavudine concentrations are much lower in the GT. 75 In our participants, GT TAM prevalence was slightly college (48%) compared with plasma (43%) despite zidovudine use in 5/9 women with TAMs in genital secretions. Drug concentration measurements in these compartments is necessary to substantiate the occurrence of DRMs equally a result of decreased drug penetration in the GT. Regarding NNRTIs, the predominance of efavirenz/nevirapine-associated G190A was observed, confirming its fitness advantage on drug force per unit area, despite its relatively depression-level resistance. 81–83 Notwithstanding, G190A confers intermediate-level resistance to etravirine in synergism with Y181C, a apropos combination constitute in plasma (14%), PBMCs (5%) and genital secretions (x%), that could interfere with its use in 3rd-line regimens. 84 Similar concerns were observed in 10% (plasma), xv% (PBMCs) and 14% (genital secretions) of women with E138A/Yard/Q, conferring resistance to rilpivirine. 85
Genotyping of proviral Deoxyribonucleic acid can shed light on archived viruses and resistance to previous drugs which might touch on resistance evolution. 85–88 Indeed, genetic distances between PBMCs and the consensus sequence were lower than other compartments suggesting earlier sequence archival. College genetic distances between compartments shows that observed discordances were acquired by differential evolution every bit a consequence of compartment-specific genetic differentiation among anatomically separate viral populations. DRMs in PBMCs that are non detected in plasma accept been previously observed and may be transmitted or re-emerge upon Fine art to which they provide selective advantage. 35 , 73–75 Increased HIV transmission run a risk is seen with higher genital HIV-ane RNA and our data suggest that resistance mutation aggregating in women with undetected virological failure could atomic number 82 to increased risk of transmission of resistant HIV-one variants. 89
The chief limitations of this study are its pocket-sized sample size and cross-exclusive design, restricting our ability to strongly accost hypotheses. In improver, plasma and GT drug concentrations were not measured, which might explain resistance discordances; GVLs for women with suppressed PVLs and pre-treatment resistance were unavailable; drug resistance testing was population-based; Gram stain was not washed to diagnose bacterial vaginosis, just wet mount was used to diagnose sexually transmitted infections, molecular-based testing was not done for trichomoniasis and herpes, and syphilis testing was too not done. Lastly, though tenofovir-based first-line regimens are currently preferred, zidovudine/stavudine-based regimens, more unremarkably reported here, are still in use in India as culling regimens, making results relevant.
In conclusion, GT viral shedding and archival, high-level resistance and discordance across compartments with genital/proviral DRMs not detected in plasma of South Indian women on starting time-line ART may result in their hidden transmission and/or re-emergence, which is likely to accept a negative affect on treatment result. Whether such high resistance levels and discordances would be minimized by routine viral load monitoring, whether they should lead to incorporation of plasma/proviral genotyping or whether they advise the need to monitor GVL and genital resistance to reduce the risk of ART failure and resistance conquering and transmission, remains to exist adamant.
Acknowledgements
Function of this work was presented as a poster at the Twentieth International AIDS Briefing, Melbourne, Australia, 2014 (Poster no. MOPDA0106).
We are most grateful to the clinical and laboratory staff at YRG-CARE, VHS, Chennai, India, for their facilitation of the study.
Funding
Funding was provided by: the Indian Council for Medical Research (ICMR), New Delhi, Republic of india; the Providence/Boston Heart for AIDS Research (CFAR) (P30AI042853); RO1AI108441; and the Brown Tufts AIDS International Grooming and Enquiry Program (AITRP; D43TW000237).
Transparency declarations
None to declare.
Supplementary data
Figures S1 and S2 and Table S1 are available as Supplementary data at JAC Online.
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Genital shedding of resistant human immunodeficiency virus-ane among women diagnosed with treatment failure by clinical and immunologic monitoring
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© The Author(s) 2018. Published by Oxford University Printing on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, delight electronic mail: journals.permissions@oup.com.
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Source: https://academic.oup.com/jac/article/73/8/2152/5003036
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